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2014_0723 CHECK ONE: LRRIGATION DOMESTIC FIRELINE BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS I.D. # LOCATION OF SERVICE: , f ? � p The backtlow prevention assembly detailed below has been tested and maintained as required by TNRCC regulations and is certified to be operating within acceptable parameters. TYPE OF ASSEMBLY C Reduced Pressure Principle 0 Pressure Vacuum Breaker lg._ Double Check Valve © Atmosphere Vacuum Breaker Manufacnaer Size ' • Model Number / C , �� O Located At Serial Number ) _ f ig‘.- 7 REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BRF sKER D ouble Check Valve Assembly 1 1st Cheek tad Check: Relief Valve Air Inlet Check Valve Initial Test DC- Closed 2 ` 4 -° Closed Tight K Opened at Opened at nsid p A i Tight � Leaked o vsid vsid J �/y�' RP- vsid Z Leaked O Did not Open O Leaked 0 Repairs and Materials Used Test Agar DC- Closed Closed Tight o Opened at Opened at vsid Repair Tight vsid vsid RP psid The above is certified to be true. Firm Name Certified Tester 7 y� le P\I Aftte I 71 �— Firm Address 20 2- elLv. erP Cert. Tester No. e�A-4/' Date ' Z 3 - Gauge # /31 LE7 c,Lp Date last accuracy tested White - Customer's Copy Yellow - City Copy Pink - Tester's Copy